Obstetric care in a rural family practice

Obstetrical care in the United States is becoming more difficult for rural populations to obtain. Fewer family physicians are providing obstetrical services. This study is a report of one family physician's obstetric experience in a small rural town. In a series of 67 obstetrical patients, 8 percent of the deliveries occurred outside of the hospital. The rate of Cesarean section was 3 percent, significantly less than the greater than 20 percent national average. There was 1 premature delivery, and no infant deaths. These figures compare well with national averages and show the need for family physicians to provide obstetrical care in rural areas.     

Moonlighting policy and practice in family practice residencies

Moonlighting by residents is a controversial, but little-studied topic. A survey on moonlighting policy and practice was sent to all family practice residency program directors, and an 87 percent response rate obtained. Moonlighting is permitted by 97 percent of nonmilitary programs and is generally thought of by program directors as a positive educational experience. It is practiced by over two thirds of the second- and third-year residents in programs that monitor moonlighting. These residents spend an average of 28 hours each month moonlighting. The most commonly used moonlighting sites are hospital emergency rooms, followed by coverage for private practice physicians. Seventy percent of programs require approval for extracurricular work activity. Only 23 percent of residencies limit moonlighting for all residents, but 47 percent have had occasion to deny moonlighting privileges to individual residents.     

Forensic training in family practice residencies

Knowledge and skill in forensic medicine are important in primary care not only for defensive purposes but also because of potential therapeutic value in patient care. The major role in future mental health services envisioned for primary care physicians makes such training especially important. A national survey of family practice residency programs reveals that 47 percent of programs do not address forensic aspects of medical practice. A model forensic medicine curriculum is described that would require minimal adjustment of existing programs. The need for inclusion of forensically qualified clinicians in training programs for primary care physicians is evident.     

A new method for measuring continuity of care in family practice residencies

Continuity of relationship between physician and patient is a fundamental aspect of the health care provided by family physicians. Measurement of continuity has proved difficult, however. Commonly applied measures, usual provider of care (UPC), continuity of care (COC), and the modified continuity index (MCI), either ignore key aspects of continuity or provide misleading results. Consequently, a new measure of continuity, the modified, modified continuity index (MMCI), with a possible range of 0 to 1, was developed to overcome these problems. It was applied to a residency model practice, in which mean MMCI was found to be 0.59 (range 0.3 to 1.0). Mean COC was .41 and a mean MCI was .44. Thus, unlike COC and MCI, MMCI suggests fairly good continuity of care in this practice while still implying possible improvement. The MMCI should be useful for enhancing training and practice of family medicine.     

Ophthalmology training in US family practice residencies

Training in office ophthalmology is important in family practice residencies, especially because ophthalmology problems are common in family practice and only one quarter of medical students take structured ophthalmology clerkships in US medical schools. A joint committee of the American Academy of Family Physicians (AAFP) and the American Academy of Ophthalmology (AAO) has developed for family practice residents a core curriculum in ophthalmology listing essential cognitive knowledge and psychomotor skills. A national study on the extent and type of training currently available in US family practice residencies was performed. Based on a response rate of 82 percent, structured ophthalmology training experiences are provided on a required basis by 93 percent of the programs. Of these, 63 percent offer block rotations normally of two or four weeks' duration. Although a majority of the cognitive areas and psychomotor skills recommended by the AAFP-AAO joint committee are likely to be covered in existing family practice residencies, gaps identified in both categories call for closer attention to improving the learning experiences of residents in this field.     

Hospital care utilization in a 17,000 population sample: 5-year follow-up

The growing utilization of hospital care, especially of the services of Emergency Departments (ED), has been of great concern for many Western countries. The purpose of this study was to relate the amount of hospital care utilization to the frequency of ED visits. The study, based on a computerized medical information system, was carried out at Huddinge hospital which serves a suburban area of Stockholm, Sweden. ED visits were found to predict hospital care utilization in a 5-year follow-up of a 10% population sample. Persons who had made 2 or more ED visits during a period of 15 months before follow-up (less than 1/8 of the population sample) contributed 24% of all hospital outpatient visits, 29% of all hospital admissions and 31% of all hospital days during the 5-year follow-up period. The number of hospital outpatient visits per 100 personyears was more than 3 times higher among those who had 4 or more ED visits as compared to those who were non-visitors at the ED. Hospital admissions and days were 5 times higher. The utilization of medical specialties differed most in psychiatry, where those with 4 or more ED visits had nearly 17 times more admissions per 100 personyears than non-visitors. The difference increased gradually with increasing number of ED visits and was also evident in each age group. The mortality was also significantly increased for those with several ED visits. Higher migration in the latter group may besides indicate social instability.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cost-benefit analyses of California family practice residencies

Several national commissions have recommended that family practice residency training be subsidized, but without stating how much support is needed. Financial studies of graduate medical education have used the methods of cost allocation or joint-products cost analysis. Previous cost-allocation studies indicate that one third of family practice residency costs are met by extramural subsidy. Cost reports of eight California public hospitals with a single family practice residency program were evaluated for the 1984-85 fiscal year. Discrepancies in the education costs reported to Medicare and those reported in state hospital disclosure reports demonstrate the arbitrary nature of the cost-allocation method. The Medicare medical education reimbursement was an average of $20,444 per resident. State and federal grants provided an average of $5,190 per resident. The Medicare payments and grants met an average of 35.7% of the education costs reported to Medicare. A joint-products cost analysis was used to estimate the pure cost of education in an 18-resident family practice residency. Replacing the residency with salaried physicians would have decreased the hospital's net return by $143,534. If neither grants nor Medicare education payments had been received, elimination of the program would have increased hospital net return by $428,083.     

Teaching colposcopy and androscopy in family practice residencies

Addressing the widespread human papillomavirus and genital epithelial dysplasia epidemic requires mastery of colposcopy, androscopy, and cryotherapy. Implementing a family medicine residency training program for these skills requires identifying a faculty facilitator to consider the issues of time, cost, caseload, reimbursement, specialist support, personal training, and office impact related to this training. Experience with teaching these skills in a community-based family practice residency indicates that startup costs range from $10,000 to $20,000. Residents will initially require from 30 to 60 minutes to provide a complete examination. All procedures require precepting by trained faculty and adherence to established protocol. The most frequent indications for these procedures include evaluating the abnormal Papanicolaou smear, visible cervical abnormalities, or evidence of clinical papillomavirus infection in either sex. Experience suggests that over 90% of cervical dysplasia can be managed entirely in the residency outpatient setting. These procedures have become the most common outpatient procedures performed, surpassing all others combined. Referrals to the residency for these procedures are readily available. Strategies for developing curriculum, literature review, learning materials, and training workshops are presented. Colposcopy, androscopy, and cryotherapy are appropriate additions to the training curriculum of family practice residencies.     

Obstetric outcomes in a rural family practice: an eight-year experience

There has been debate in some quarters of whether family physicians should do obstetrics and of whether rural hospitals should provide obstetric services. Forks, Washington, is a remote logging town where family physicians and midlevel practitioners have been the sole providers of labor and delivery services. Forks offers an opportunity to evaluate the quality of an isolated rural family practice obstetric service. A retrospective audit of all labor and delivery patient charts at Forks Community Hospital from 1975 to 1983 was undertaken; 1,052 charts were abstracted with 36 factors of morbidity, mortality, and intervention examined. The results, when compared with similar studies in the literature, provide evidence of good performance. In addition, a relatively high-risk obstetric population was served with favorable outcomes. Family physicians and rural hospitals can provide high-quality obstetrical services.     

Entry of US medical school graduates into family practice residencies: 1999-2000 and 3-year summary

This is the 19th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family practice residency programs. Approximately 13.4% of the 16,143 graduates of US medical schools between July 1998 and June 1999 were first-year family practice residents in 1999, compared with 15.4% in 1998 and 16.6% in 1997. Medical school graduates from publicly funded medical schools were almost twice as likely to be first-year family practice residents in October 1999 than were residents from privately funded schools, 16.2% compared with 9.3%. The West North Central region reported the highest percentage of medical school graduates who were first-year residents in family practice programs in October 1999 at 20.6%; the Middle Atlantic and New England regions reported the lowest percentages at 7.7% and 8.0%, respectively. Nearly half of the medical school graduates (48.4%) entering a family practice residency program as first-year residents in October 1999 entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the average percentage for each medical school for the last 3 years. Also reported are the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family practice residency programs, based on estimates provided by the American Association of Colleges of Osteopathic Medicine.     

Entry of US medical school graduates into family practice residencies: 2001-2002 and 3-year summary

This is the 21st report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family practice residency programs. Approximately 10.9% of the 15,900 graduates of US medical schools between July 2000 and June 2001 were first-year family practice residents in 2001, compared with 12.8% in 2000 and 13.4% in 1999. Medical school graduates from publicly funded medical schools were more likely to be first-year family practice residents in October 2001 than were residents from privately funded schools, 12.7% compared with 8.4%. The West North Central region reported the highest percentage of medical school graduates who were first-year residents in family practice programs in October 2001 at 15.2%; the Middle Atlantic and New England regions reported the lowest percentages at 8.0% and 7.2%, respectively. Nearly half of the medical school graduates (48.0%) entering a family practice residency program as first-year residents in October 2001 entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the average percentage for each medical school for the last 3 years. Also reported are the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Councilfor Graduate Medical Education-accreditedfamily practice residency programs, based on estimates provided by the American Association of Colleges of Osteopathic Medicine.     

Entry of US medical school graduates into family practice residencies: 2002-2003 and 3-year summary

This is the 22nd report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family practice residency programs. Approximately 10.3% of the 15,810 graduates of US medical schools between July 2001 and June 2002 were first-year family practice residents in 2002, compared with 10.9% in 2001 and 12.8% in 2000. Medical school graduates from publicly funded medical schools were more likely to be first-year family practice residents in October 2002 than were residents from privately funded schools, 12.3% compared with 7.3%. The Mountain and the West North Central regions reported the highest percentage of medical school graduates who were first-year residents in family practice programs in October 2002 at 16.3% and 15.9%, respectively; the Middle Atlantic and New England regions reported the lowest percentages at 6.1% and 5.6%, respectively. Nearly half of the medical school graduates (48.6%) entering a family practice residency program as first-year residents in October 2002 entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the average percentage for each medical school for the last 3 years. Also reported are the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family practice residency programs, based on estimates provided by the American Association of Colleges of Osteopathic Medicine.